How not to poison the elderly

September 9, 2013

It was in my father-in-law’s 89th year that I grasped what his problem might be. His memory was good, lucky man. His physical ailments were not life-threatening. But he could hardly keep his eyes open. He’d nod off to sleep, wake up, complain of nausea, then nod off again. It occurred to me suddenly: this is what heroin addicts did. I’d seen a few in the ‘80s. They’d constantly be nodding off. My father-in-law was not a heroin addict; he was a teetotaller. For the previous two years, he’d barely been able to walk or feed himself. He’d become a ghost of the raconteur who’d charmed the staff in his low-care hostel. Doctors hadn’t helped. We’d accepted this was what growing old looked like, a grim vigil in death’s waiting room. But one day I turned to my husband and said, “I think he’s drugged to the eyeballs.”

And he was. He was a victim of a common problem – over-medication of the elderly. Or as the geriatrician, Dr Tom Gibian, then at Bankstown Hospital, was to put it more bluntly: Don Ireland had been poisoned. Like thousands of elderly Australians, he’d been poisoned by the prescription medicines that were supposed to help him. And we, his son and daughter-in-law, had thought this bombed-out state “normal” for a man in his late 80s. It wasn’t. It’s what can happen when you’re taking 17 different medications prescribed over time by too many doctors, working in isolation from one another.

I’d hoped the situation had improved since 2005. But at a conference last week held by the Australian Association of Gerontology I learnt it had hardly changed. “It may even have got worse,” Dr Vasi Naganathan, associate professor in medicine at Sydney University’s Centre for Education and Research on Ageing, told me. “There are more medicines, more specialists……”

Around 140,000 people are admitted to hospital each year due to adverse effects of their medication; many of them are elderly. Among people aged over 75, about 60 per cent take five or more different medications. People living in aged care facilities take on average ten different medications. A 78 year-old woman, at death’s door, was admitted from a nursing home to the Concord Hospital, Sydney, with a medication list that showed she was on 23 different pills, the conference was told. “The most I’ve seen is 36,” said David Le Couteur, professor of geriatric medicine at the University of Sydney, who describes such poor prescribing as “a human rights issue.”

The ABC Lateline program has revealed that as many as 6,000 elderly Australians a year could be dying prematurely because of over-prescription of anti-psychotic drugs to control behaviour. The use of anti-depressants in nursing homes is also high; and amazingly, it’s highest among people in their 90s despite no evidence they’re a particularly depressed or anxious group. “It’s now getting to the point where old age is a psychiatric diagnosis,” Professor Le Couteur told the audience.

Drugs are trialled on younger people, not on those over 65, and certainly not on people who take multiple medications. “It’s mind-boggling that you would take a frail, old person and put into them 10, 20, 30 chemicals designed to treat illnesses in younger people,” he said.

As we saw in Don, poor prescribing in older people increases the risks of things going wrong: falls, frailty, impaired thinking, and disability. If it doesn’t kill them, and sometimes it does, bad prescribing leads to unnecessary suffering. One study has shown that 10 per cent of hip fractures in Australia are linked to benzodiazepines used for insomnia and anxiety. Another study of aged care residents with dementia found half were taking at least one potentially inappropriate medication. Professor Le Couteur said being on an anti-psychotic drug if you have dementia was the equivalent of advancing the disease by a year.

Yet medications, prescribed wisely, have contributed to people living longer. My mother’s relative good health at 85 is due in part to her haematologist having carefully monitored her potent drugs for years. It would be wrong to deprive the elderly of drugs for potentially treatable conditions just because they were old; and of course, wrong for the elderly to stop taking medicine without asking their doctor.

The best advice for those caring for elderly parents, and for the elderly themselves, comes from Karen Kaye, acting CEO of NPS MedicineWise. It’s the non-profit group funded by the Department of Health and Ageing to promote quality use of medicines. “Take regular stock,” she says. “’What is it I want to achieve from taking this medicine and is it really necessary?’” GPs can be asked to do an informal review of medications; and they can also order a formal Home Medicines Review from a pharmacist who visits the home.

NPS MedicineWise has just launched a new educational program for doctors and health workers about drugs and the elderly. But with 100 workers on the ground to contact the nation’s many thousand GPs and health professionals, it’s an uphill battle against the power of pharmaceutical companies, the isolation and inadequacies of doctors, and the desire of patients to be given a pill.

Don got a new life. We should have acted sooner. Dr Gibian weaned him off 14 of his 17 medications. It was like turning on a light switch. He came back to us, humour, stories and all. He had about three good years before one last illness took him out just short of his 94th birthday.

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